Incidence of IT Band Syndrome
The warm summer weather is the perfect setting for people to get outdoors and participate in the activities they enjoy. However, too much of a good thing can lead to overuse injuries. Iliotibial band syndrome, or ITB syndrome, is one of these injuries. It is also a common injury that occurs with the athletic population, accounting for 22% of all lower extremity injuries. (1) In cyclists, it accounts for approximately 15% of injuries (2) and is the leading cause of lateral knee pain in runners. (3) Corrective exercise programming can greatly benefit those at risk for ITB syndrome.
Anatomy and Pathophysiology
The IT band is a thin band of connective tissue (fascia) with proximal attachments to the pelvis through the tensor fascia latae and gluteal muscles. Distally it inserts into the lateral femoral condyle and Gerdy’s tubericle located on the anterior lateral surface of the proximal tibia. (4) Given the IT band encompasses the joints of both hip and knee, injuries can result from muscular deficits in either the lumbopelvic region or localized at the knee. The IT band helps to stabilize the knee with its associated muscles acting to abduct and externally rotate the hip.
Given the attachments sites above and below the knee joint, activities which involve repetitive knee flexion and extension are most prone to injury. This typically occurs when the knee if flexed between 0 and 30 degrees with the greatest friction occurring at 30 degrees. (5) This can be exacerbated with adduction or valgus knee collapse, which increases the tension on the IT band.
Signs and Symptoms
People who experience ITB syndrome typically complain of sharp or burning pain just above the joint line on the outside of the knee. The pain is generally worse at the beginning of the exercise and tends to lessen as the muscles warm up, however, if the activity continues then the pain will worsen and could potentially halt the activity. Pain is also most noticeable when running downhill or just after the heel strike phase of the gait cycle. (6)
There are several factors that may contribute to the onset of ITB syndrome. These include the extrinsic factors related to training methods, such as improper shoes, incorrect bicycle fitting, or participation in repetitive activities including running and cycling. For example, a rapid increase in mileage and hill training for a runner may lead to an IT band injury, while having the bicycle seat too high or too far back causes the cyclist to reach for the pedal putting excess tension on the IT band. (2, 7) Intrinsic factors include weak gluteal musculature, knee valgus, IT band tightness, and weak core musculature to highlight a few common findings.
A squat assessment is a good place to start and, when done properly, can provide you with valuable information about a client and potentially reduce their risk of injury. The lower body must properly work in unison to move through triple flexion and extension of the hip, knee and ankle giving the trainer valuable insight helping to identify musculature stability and dysfunctional movement patterns. (8)
As the client squats down pay close attention to if the outside of their knee crosses their medial malleolus. This movement dysfunction may be the result of hip musculature weakness, an ankle dorsiflexion problem or over pronation.
Pelvic rotation and tilting should be assessed as this could be due to compensation for the low back or hip musculature. Monitor the level of the hips in relation to the floor.
Once the lower body movement pattern has been assessed, testing the core musculature is essential since the core functions as the centre of all movement along the kinetic chain. (9) There are several studies in the literature that demonstrate the importance of proximal core stability and its relationship to a decrease in lower extremity injuries. (10)
Side Bridge Test
The side bridge test as described by McGill is an easy and functional way to assess the lateral core musculature. To perform, have the client positioned on either their right or left side to start with the elbow underneath their shoulder and the top foot in front of the other. Have them lift their hips off the floor and place the hand of the top arm on the opposite shoulder. A straight-line position should be held for the duration of 90 seconds for males and 75 seconds for females. (11) Look for any movement faults including hips swaying forward or back, hips sagging downward or shoulders rotating forward. Repeat on the opposite side and compare time.
Although there is some debate in the literature in regards to the exact mechanism of ITB syndrome as to whether it is caused by weakness of the gluteal muscles or due to overuse and subsequent pain causing motor control changes, the one thing that is clear is that exercise is essential for a resolution of symptoms. This is demonstrated in several studies showing a 90% resolution with conservative care consisting of corrective exercise (12).
An effective yet simple exercise, to begin with, is the hip bridge utilizing a resistance band. Researchers Choi and colleagues found that gluteus maximus EMG activity was significantly greater while anterior pelvic tilt angle was significantly lower in the glute bridge with isometric hip abduction compared to the glute bridge without the band. Therefore, they concluded that performing glute bridges with isometric hip abduction against isometric elastic resistance can be used to increase gluteus maximus EMG activity and reduce anterior pelvic tilt during the exercise. (13)
Hip Bridge with Resistance Band – Begin lying on the floor with knees bent and feet flat on the floor. Place a resistance band around thighs just above knees. Slightly abduct legs while simultaneously performing a hip bridge. Slowly lower hips to start position without bringing knees together. Perform 3 sets of 10 repetitions.
The Side Lying Hip Abduction is a great way to isolate the glute medius. Distefano and colleagues looked at gluteal activation among common exercises and identified this as one of the top exercises. (14)
To perform this exercise, begin lying on one side on the floor with the top leg extended and the bottom leg bent for added stability. The top leg should attain a straight line through hip and shoulder. Activate core muscles. Lift top leg upward, abducting legs. Slowly return to start position and repeat for 3 sets of 10 repetitions.
Once you have isolated the gluteus medius you can now integrate a more functional exercise with the lateral band walk. Increased hip abduction strength has been shown to improve the ability of female athletes to control lower extremity alignment. (14) When performing this exercise, the stepping motion should be performed in a semi-squat position with the knees bent rather than an upright straight leg position in order to generate greater gluteus maximus and medius muscle activity. (15)
Begin standing with a resistance band looped just above the knees. Maintaining bend in knees, step out sideways, keeping toes pointed forward. With the lagging leg, side steps slowly towards the leading leg, placing the foot down at hip width distance away. Repeat for 10 steps in on direction and return in the opposition direction. Perform 3-4 sets.
The side plank now performed as an exercise is a great way to build core strength and endurance. However, it is important to keep the hold and resultant isometric contraction to 10 seconds or less, building strength through endurance with repetitions and not by increasing the duration. Mc Gill and colleagues showed this is the best approach as it helps keep muscles from cramping and minimizes lactic acid build up. (17) Therefore, start by performing 3-5 repetitions for 10 seconds each, gradually adding more repetitions.
Standing IT Band Stretch
Since the IT band attaches to the pelvis through the tensor fascia latae and gluteal muscles it is important to stretch these muscles as well. The standing IT band stretch pictured above was found to be the most effective as Fredericson and colleagues showed an average length increase of 11%. To perform, stand upright with the IT band to be stretched positioned behind the opposite leg with feet shoulder’s width apart and then lean to the side until a “good stretch” is felt. Hold this for 30 seconds and repeat 3 times. This can be performed either with or without the arms above head, however with the arms down this stretch is slightly less effective.
All the above-displayed exercises are easy to execute and include minimal risks if performed as described. To achieve satisfying results, it is important to do them on a regular basis and for a minimum of 4 weeks. The general guideline for progressing called the “10% rule,” where total training (intensity, frequency, duration, or any combination), is not increased more than 10% per week. Although there are many approaches to hip strengthening hopefully this has provided insight into some basic strengthening strategies. Should your client’s condition worsen at any time, an evaluation with a medical professional would be warranted.